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Being a Physician Means More
Than Satisfying Patient Demands:
An Ethical Review of Esthetic
Treatment in Dentistry
A beautiful smile, more success in your ca-
reer, better opportunities in your private life—
dentistry promises all of these things, more
or less explicitly, when advertising esthetic
treatments. On the surface, it would seem
almost absurd for patients not to accept
these grand “medical” promises. What
could be wrong with medicine helping peo-
ple not only cure or prevent their diseases,
but also be more successful in their profes-
sional and private lives? Furthermore, in re-
cent years it has been emphasized that cli-
nicians must respect their patients’ autono-
my and avoid deciding what is best for each
patient. In many areas of medicine, the pa-
tient is perceived and presented mainly as
a client, and in turn the patient shows a
client-like behavior with his or her percep-
tion of entitlement. From an ethical perspec-
tive, however, a question must be raised: Is
this reorientation of the patient-clinician re-
lationship acceptable? In the realm of den-
tistry, particularly the esthetic promises of
modern dentistry, the ethical limits of such
a shift in identity become evident.
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Giovanni Maio
Chair of Bioethics
Institute of Medical Ethics and
History of Medicine
University of Freiburg, Germany
Phone: 49 761 2035034
E-mail: giovanni.maio@uniklinik-
freiburg.de
Esthetic treatment:
helpful or harmful?
As an example, let us look at bleaching, a
procedure that is labeled “medical” but is
at its core a marketing instrument, perhaps
even more a part of the beauty industry
than dentistry. Of course, the “clients” can
decide for themselves whether they want to
have brighter teeth, but in granting this re-
quest, medicine is acting immorally, no
matter how vehement the patient’s wish
may be. Why is this an immoral act? First,
a steep price is paid for bleaching the
teeth—not only financially, but also and
more importantly because the tooth itself
suffers damage to its physiologic function.
Of course, one might argue that most clini-
cians will explain these risks to the patient;
therefore, if the patient wants to accept
these consequences, they have every right
to do so. From a legal point of view there
can indeed be no objection to this argu-
ment. However, an act permitted by law
can still be ethically questionable. In this
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case, there are still serious ethical con-
cerns. Can it truly be a physician’s function
or purpose to consciously harm patients?
Can it truly be a physician’s function or
purpose to jeopardize physiologically im-
maculate teeth simply because his or her
patients want brighter teeth?
The creed “I will apply dietetic measures
for the benefit of the sick according to my
ability and judgment; I will keep them from
harm and injustice” is at the core of the
Hippocratic Oath. How can a dental clini-
cian today take the moral responsibility for
not keeping their patients from harm?
Increased well-being or
increased sales volume?
Many dental clinicians justify esthetic inter-
ventions by arguing that a medically cre-
ated “beauty” will contribute to the client’s
well-being. The World Health Organization
(WHO) has defined health as a state of
complete physical, mental, and social well-
being. Thus, it seems justifiable to consid-
er purely esthetic interventions in dentistry
as medical treatments, since they serve the
purpose of “health” as defined in this way.
It must be considered, however, that this
WHO definition is not necessarily a sound
basis. For if mental well-being was the aim
of medicine, then debt counseling, for ex-
ample, would be a medical intervention,
since it leads to greater well-being and al-
leviates suffering for heavily indebted peo-
ple. Thus, “well-being” as such is not suffi-
cient to characterize a medical interven-
tion. Above all, this example highlights that
if we categorize these measures as medi-
cine, it will lead to an illegitimate patholo-
gization of normal conditions. This is pre-
cisely what occurs on a regular basis
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when esthetic dentistry posest as medicinen
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and purports to solve problemsethatn are
not by their nature medical problems. Af-
ter all, what is the basic problem behind a
person’s request to have healthy dentition
esthetically modified? If a person is suffer-
ing as a result of the appearance of their
teeth, it is not the teeth themselves that
cause the suffering; rather, the person is
suffering from a lack of self-confidence. If
a physician really wanted to help, he or she
would refrain from such purely cosmetic
interventions, and attempt to determine—
as a physician—the underlying cause for
the patient’s condition of suffering. A physi-
cian who simply treats the patient’s teeth is
ignoring the underlying problem.
In these cases, the problems treated
with the help of medical technology are not
medical but distinctly social in nature. They
are social because the underlying cause
for such requests is our highly competitive
society, not the patient’s appearance as
such. One could argue, of course, that to
change society is not easy; however, this
does not justify harmful medical proce-
dures. Dentists would be true physicians if
they told their clients that there is a more
effective and, most importantly, longer-last-
ing treatment option: to work on them-
selves and their personality. Clinicians who
believe they can solve a lack of self-con-
fidence with medical technology, and who
pretend to do so, cannot seriously be in-
terested in their patients’ well-being. More
likely, they are interested in their revenues.
When an economic objective supersedes
the objective of the patients’ well-being,
the treatment cannot be considered as a
true medical procedure—only as a busi-
ness transaction offered by a service
provider who is more or less unconcerned
about the welfare of the consumer.

Exploiting patients’
insecurities
Physicians may fail to recognize medical
ethics in another serious way. While many
physicians feel that offering cosmetic
measures is merely reacting to a patient’s
needs, we must remember that a physi-
cian performing cosmetic treatment is still
acting as a physician, and this fact has far-
reaching consequences. What makes a
physician a physician? The character of a
physician is determined less by the choice
of treatment methods and more by the fact
that all physicians know they are subject to
a certain set of ethics. A physician acting
as a physician would never carry out any
treatment known to be harmful. A physi-
cian acting as a physician would only car-
ry out treatments that have a chance of
success and will presumably help the pa-
tient. When physicians perform cosmetic
interventions under the guise of medical
treatment, this has considerable conse-
quences—people will begin to assume, “if
this intervention is carried out by a physi-
cian, it must make sense in some way to
bleach teeth or to place jacket crowns.” In
other words, a physician’s actions can
make patients believe that it is worth
changing geometrically imperfect denti-
tion. The more cosmetic interventions cli-
nicians offer, the more deficient their un-
1
treated patients will feel. If the explicit goal
of dentistry becomes to enhance the ap-
pearance of teeth, jaws, and dental
restorations, this will ultimately lead many
people to feel more inferior than ever, as
these measures become increasingly
widespread.
This issue becomes even more serious
if a dental clinician not only carries out
cosmetic interventions at the patient’s re-
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quest, but also begins advertising
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terventions. Advertising has the purpose
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creating a need; through advertising, a
physician has no other aim but to give
people the feeling that they could not pos-
sibly be happy without this cosmetic inter-
vention. People who used to feel good
about themselves may lose their self-con-
fidence, and believe that only through cos-
metic intervention can their positive self-
image be restored. Thus, it is obvious how
seriously advertising thwarts the physi-
cian’s purpose to help patients. If the pa-
tient’s well-being really was the true motive
and underlying aim of a physician’s ac-
tions, advertising would not be the appro-
priate means to achieve this goal. Esthetic
advertising serves only to unsettle clients’
self-confidence; it does nothing to help
build it.
Promoting a superficial
culture
Physicians who provide treatment based
solely on their patients’ demands—without
critically analyzing these demands—risk
confirming certain beliefs that are in them-
selves worth criticizing. For example, we
must ask: What does it say about human
beings if we assume that it is only possible
to lead a life worth living if we have a cer-
tain physical appearance? How can we
make personal acceptance contingent up-
on the color or shape of someone’s teeth?
It used to be that paying excessive atten-
tion to outer appearance was seen as a
depraved expression of vanity and selfish-
ness. But even if we wanted to legitimate
the wish to be beautiful, it should be con-
sidered that some ancient philosophers
defined beauty only in association with
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virtue. In certain ancient traditions, beauty
and virtue were seen as two sides of the
same coin. Plato saw manifestation of
virtue in the truly beautiful. Prior to that,
Demokrit distinguished between genuine
beauty and a purely visual appeal. In the
Middle Ages and in early modern history,
there was a distinction between ideal
beauty—embodying virtue—and a sensual
beauty that was merely depraved. To which
kind of beauty will dentistry respond?
Today, beauty has been reduced entire-
ly to physical appearance. Consequently,
the search for beauty is no longer the
search for holistic integrity. In fact, today’s
concept of beauty is reflective of a society
geared toward performance and function-
ality. If we examine this idea further, we
cannot help but recognize that medicine’s
attention to pure cosmetics is partially re-
sponsible for the societal primacy of vani-
ty, youthfulness, and superficiality devoid of
meaning. Dentistry may not be the origina-
tor of this problem, but by making esthet-
ics officially and often unscrupulously one
of its central functions, it both confirms and
promotes these modern perspectives.
Medicine that commits itself to pure esthet-
ics is an accomplice of a society guided by
2
inanity and vanity. The obsession with
physical appearance represents part of a
lamentable entanglement of medicine.
This kind of medicine has dismissed its
quintessential purpose to help people who
have fallen ill and has stooped to become
an accessory of an ideology-driven con-
sumer society.
Conclusions
It cannot be concluded that all cosmetic in-
terventions in dentistry raise ethical issues.
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te who are
For there are many physicians n
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guided by noble ideals—not by profit—
e
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when performing esthetic procedures.
Moreover, there are some issues regard-
ing outer appearance that can cause suf-
fering. In these cases, esthetic intervention
can indeed be a medical remedy. Never-
theless, there is a fine line between service
to people and immoral marketing of “med-
ical” promises. The issues discussed in
this article are meant to illustrate that es-
thetic dentistry can only maintain its cred-
ibility and identity as a medical discipline if
it acts responsibly in selecting indications.
Physicians who act only to satisfy the de-
mands of their “clients” risk being relegat-
ed to a mere auxiliary. Such a physician
might as well be a craftsman. It is the criti-
cal evaluation of a patient’s wish—this im-
plementation of responsibility—that makes
a physician a physician. In practical terms,
this means that a good physician will al-
ways reflect on the patient’s wish for an es-
thetic intervention. A good physician will
not treat patients according to their wishes
until he or she can be sure that a patient’s
request is not based on exaggerated fan-
tasies or difficult anthropologic preconcep-
tions. In these cases, further conversations
with the patients are of particular impor-
tance, and if doubt about the request for
treatment remains, the request would have
to be rejected.
If esthetic dentists see themselves as
physicians, they should propagate unbi-
ased ideas of beauty that view it as the
overall impression of a person, not just his
or her physical appearance. The philoso-
pher Gernot Böhme defined beauty as a
way of being and not as a rating attached
to a person.3 In this way, beauty cannot be
achieved through medical technology; in-
stead, it must be obtained by working on

the inner self, and examining and improv-
ing one’s charisma, behavior, communica-
tion, and attitude. Esthetic dentistry should
advocate a concept of beauty that does
not imply the standardization of all people
through technology, but rather attributes
positive connotations to the diversity of hu-
man features. Dental clinicians would often
be of better service to patients with an ef-
fort of counseling and persuasion than
with invasive procedures.
It may be the case that “better” looks are
associated with a competitive advantage;
however, this advantage—be it in private or
professional life—has two pitfalls. First, what
kind of people form a positive attitude to-
ward someone based solely on appear-
ance? Such an opinion will likely be short
lived. In addition, we must consider that
References
1. Maio G. Ist die ästhetische 2. Maio G. Ethische Grenzen kos-
Chirurgie überhaupt noch metischer Maßnahmen in der
Medizin? Eine ethische Kritik. Zahnheilkunde. Zahnärztliche
Handchirurgie, Mikrochirurgie, Mitteilungen 2006;10:78–83.
Plastische Chirurgie
2007;39:189–194.
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such an advantage could just tas well be
ot
n
fo r
achieved through improved charismae nand
social behaviors, not only through the out-
er appearance. If a physician takes help-
ing his or her patients seriously, he or she
would help patients to acquire more social
confidence, as this would likely achieve
the same competitive advantages at a
much lower cost.
An esthetic dentist who, acting as a
physician, “helps” patients in a way that is
risky, expensive, and less effective than
other measures of acquiring social or per-
sonal success does not do justice to the
purpose of a physician. Therefore, esthet-
ic dentistry as a medical discipline can on-
ly have a future if it recovers what has been
lost: people’s trust in its moral integrity.
3. Böhme G. Leibsein als Auf-
gabe. Leibphilosophie in prag-
matischer Hinsicht. Kunsterdin-
gen: Die Graue Edition, 2003.
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